e-Consult 2022 | The Office of Dr. Josh Hamilton APRN LLC

Question Title

* 1. Patient Information

Patient's name *

Person completing this form

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 2. Rate your MOOD for the past two weeks:

Sad - Depressed

"Normal"

Too Happy - Manic

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 3. Rate your ANXIETY LEVEL for the past two weeks:

None

Moderate

Panic Attacks

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 4. Tell us about your SLEEP pattern for the past week:

Taking too long to fall asleep

Waking up in the middle of the night

Waking up too early in the morning

Nightmares

Vivid dreams

More information about my SLEEP PATTERN:

Question Title

* 5. Since your last appointment, has your WEIGHT:

Increased

Stayed the same

Decreased

Tell us about your APPETITE for the past two weeks:

Question Title

* 6. Have you taken your MEDICATIONS as prescribed?

Yes

Question Title

* 7. Are you experiencing any MEDICATION SIDE-EFFECTS?

Yes

What side-effects are you experiencing?

Question Title

* 8. Do you think your MEDICATION needs to be ADJUSTED or CHANGED?

Yes

If yes, please describe your concerns here:

Question Title

* 9. Are you participating in COUNSELING or THERAPY?

Yes

If so, please list therapist and frequency of sessions:

Question Title

* 10. Have there been any CHANGES in your OVERALL HEALTH?

No changes

I have seen my family doctor/specialist

I have started/stopped a medication

I have been treated at urgent care/ER

I have had the cold/flu

I have had other health problems since last appointment

Please describe changes in your health, including medications you've started/stopped, medical visits you've had, etc.